MEMBERSHIP ENROLLMENT FORM
GOVERNMENT MEMBERSHIP
(Federal and State)
Any pharmacist/technician who works directly for the federal government (including civil service, uniformed service, Title 38, etc.) or is retired from government employment
is eligible for APhA Government Pharmacist/Technician membership. Contract or consulting pharmacists do not qualify for Government Membership.
SECTION 1: Contact Information
Mr.
Ms.
Dr. Rank:________________________________ Other:__________________________________
FIRST NAME
INITIAL
LAST NAME
SUFFIX
DESIGNATIONS (e.g., PharmD, RPh)
PREFERRED E-MAIL ADDRESS (REQUIRED)
Providing your e-mail address allows you to receive timely updates from APhA and important news and information. APhA does not sell or distribute
member e-mail addresses.
PREFERRED FAX NUMBER
HOME ADDRESS
CITY
STATE
ZIP CODE
HOME TELEPHONE
WORK NAME & ADDRESS
CITY
STATE
PREFERRED MAILING ADDRESS:
ZIP CODE
HOME
TITLE/POSITION
BUSINESS TELEPHONE
WORK
YEAR OF GRADUATION (REQUIRED)
COLLEGE/SCHOOL OF PHARMACY ATTENDED
SECTION 3: (Required) Academy Section and Special Interest
Group Selection
SECTION 2 (Required): Membership
Category and Government Service
APhA has two Academies–APhA Academy of Pharmacy Practice and Management (APhAAPPM) and APhA Academy of Pharmaceutical Research and Science (APhA-APRS). As an APhA
member you can choose to join both Academies, but you must designate one as your Primary
Academy.
Government Pharmacist Member – $129
Uniformed Services
Civilian Employee
Government Pharmacy Technician Member – $56
Uniformed Services
Civilian Employee
Please circle the P for Primary Academy and/or the S for your Secondary
Academy.
P S APhA-APPM
P S APhA-APRS
APhA-APPM: If you select APhA-APPM as your Primary or Secondary Academy,
you have the option to join multiple Special Interest Groups (SIGs). Note: APhA Elec-
tion determines APhA-APPM leadership; SIG leadership is selected by SIG members at the Annual Meeting.
If you belong in a different membership category, please visit
www.pharmacist.com/JoinAPhA to access the appropriate
Member Enrollment Form.
Government Service – choose only one
Army
Navy
PHS
Coast Guard
VA
Federal Civilian
Air Force
State Health
Department Civilian __________________________
16041
Special Interest Groups:
Compounding
Diabetes Management
Immunizing Pharmacists
Medical Home/ACO
Medication Management
Nuclear Pharmacy Practice
Pain, Palliative Care and Addiction
Preceptor
Transitions of Care
To join a SIG e-Communities, sign up at www.pharmacist.com/apha-appm.
APhA-APRS: If you select APhA-APRS as your Primary Academy, you must designate a Primary Section for voting purposes by circling the P in front of the section.
Note: APhA-APRS Academy/Section leadership is determined by the APhA Election.
P S Basic Sciences
P S Clinical Sciences
P S Economic, Social and Administrative Sciences. WEB
Continued On Page 2 ——>
Name __________________________________________________
Phone __________________________________________________
SECTION 4: Journals & Publications
•
Members receive full access to APhA’s DrugInfoLine
(www.aphadruginfoline.com), the Journal of Pharmaceutical Sciences
(JPharmSci) and Pharmacy Today.
Members also may choose between the online or print version of the Journal
of the American Pharmacists Association (JAPhA).
Page 2
SECTION 6: Your Dues Payment
Membership Dues Amount (Based on the
Membership Category):
$_____________
Optional Fees for Publications from Section 4 $_____________
Living outside the US or Puerto Rico? Add a $100 postage surcharge for mailing APhA
periodicals. (Does not apply to APO or FPO adresses.)
$_____________
* Not all members are eligible for all benefits. Please refer to www.pharmacist.com for
a complete list of benefits by member type.
Voluntary Contribution from Section 5
$_____________
•
Total Payment $_____________
•
Please select one of the following:
Access JAPhA online only! (Go green!) OR
Access JAPhA in print!
•
Bonus Benefits: APhA members are now eligible for a 20% discount
off subscriptions to Pharmacotherapy, International Journal of
Pharmaceutical Compounding (IJPC), and a 20% registration
discount to the IJPC website: www.compoundingtoday.com
(restrictions apply).
Please subscribe me to the online version of Pharmacotherapy,
official journal of ACCP, for an additional fee of $76 (20% off the $95
subscription rate). Please add $76 to the total due in Section 6.
To subscribe to IJPC, visit www.IJPC.com/Subscribe; to register for the website, visit http://compoundingtoday.com/Register.
For additional information, visit www.pharmacist.com/JoinAPhA.
A portion of your dues payment is allocated to your subscription of JAPhA ($25) and
Pharmacy Today ($14). These amounts cannot be deducted from your dues total.
Check made payable to APhA in US dollars drawn on a US bank
Credit Card:
Visa
CREDIT CARD NUMBER
MasterCard
AMEX
EXPIRATION DATE
CARDHOLDER SIGNATURE
SUBMIT ENROLLMENT FORM WITH PAYMENT:
SECTION 5: Voluntary Contribution
By Mail: Send form and payment to APhA Info Center,
P.O. Box 411, Annapolis Junction, MD 20701-0411
APhA Foundation
$50.00 USD $500.00 USD
$100.00 USD Other $_______
APhA Foundation Donation
The APhA Foundation is pharmacy’s philanthropy! Our mission is to
improve people’s health through pharmacists patient care services. Our research,
public education and recognition programs advance patient care and add value to
the health care system. Learn more at http://www.aphafoundation.org/ or
APhAfoundation.org. Make a tax deductible contribution today.
By Fax: Fax with credit card payment to: 1-240-554-2367
You will receive your new member package within 2 weeks of enrollment.
Questions? Please contact a Member Services Representative at
800-237-APhA (2742). Under IRS guidelines, the full amount of your gift to the APhA Foundation
is a deductible contribution. Contributions or gifts to APhA are not deductible
as charitable contributions for federal tax purposes. However, dues may be
deductible as an ordinary and necessary business expense. Pursuant to the
Omnibus Budget Reconciliation Act of 1993, 67% of your APhA dues is
attributable to nondeductible lobbying activity and is therefore not deductible
under Internal Revenue Code Section 162 as an ordinary and necessary
business expense. See your personal tax advisor for additional information.